**6. The role of the pillars of lifestyle medicine in the management of diabetes mellitus**

#### **6.1 The role of stress management in the management of diabetes mellitus**

Stress management is one of the pillars of lifestyle medicine. Stress can be defined as the response the body makes to any demand that is made on it. Being a diabetic is stressful already and diabetes mellitus is also stressful to the body; the worst is when there are diabetic complications. During stress, several hormones are released such as cortisol and other hormones that mobilized energy [32]. These hormones lead to hyperglycaemia as stress affects the endocrine system leading to

changes in the mechanism of metabolism of glucose. Chronic exposure to stress has several deleterious effects on the body [33]. The rise in the blood glucose following stress is not associated with physical stress alone but with any form of stress including emotional and psychosocial stress [34], which may be experienced daily.

There is an undiagnosed and underestimated incidence of depression, anxiety, the stress in diabetics [32], and there is a correlation between these mental problems with non-communicable diseases including diabetes mellitus. Some diabetics have co-morbid mental health disorders that are not recognized by the physician hence they are not diagnosed [32]. In a case–control study conducted by Krishna [34] among Type 2 diabetics on depression, anxiety and stress, there was a lower level of depression, anxiety and stress in the healthy controls compared to those diagnosed with diabetes mellitus as the diabetics had a higher incidence of depression, anxiety and stress. Hence, stress management is key in diabetes mellitus management.

Emotional problems are common in diabetics and diabetics are at risk of various emotional and psychological problems such as depression, anxiety and diabetesspecific distress [35]. One of the sources of distress in diabetes is the lifelong treatment which is required [36]. Faridah et al. [36] in their study on the relationship between emotional distress and quality of life of patients with Type 2 Diabetes Mellitus used the diabetes distress scale for their study. In this study, a significant relationship was observed using linear regression between emotional distress characteristics p-value >0.05 [36]. There was a positive relationship between glycaemic control and emotional distress in another study conducted by Strandberg et al. (2019) [37] where 319 adults with Type 1 diabetes mellitus were studied. This study proposed that during every clinical consultation with a diabetic, depression and diabetes specific emotional distress should be watched out for [37].

In a South African cohort study conducted to investigate distress related to diabetes mellitus in patients with Type 2 Diabetes Mellitus, diabetes distress scale was used for this study. Distress was seen in 44% of the study participants [38]. This study recommends that attention should be paid to the psychological requirements of the patients as it has a great impact on the outcome of the disease [38]. In a randomized trial of Type 2 Diabetes Mellitus by Survit et al. [39], a significant reduction in HbA1c occurred following education on stress management (0.5%). There was a lower level of the HbA1c after one year in subjects who were educated on stress management [39].
